Melvin S. Swanson

Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.

ObjectiveThis report documents that the gastric bypass operation provides long-term control for obesity and diabetes. Summary Background DataObesity and diabetes, both notoriously resistant to medical therapy, continue to be two of our most common and serious diseases. MethodsOver the last 14 years, 608 morbidly obese patients underwent gastric bypass, an operation that restricts caloric intake by (1) reducing the functional stomach to approximately 30 mL, (2) delaying gastric emptying with a c. 0.8 to 1.0 cm gastric outlet, and (3) excluding foregut with a 40 to 60 cm Roux-en-Y gastrojejunostomy. Even though many of the patients were seriously ill, the operation was performed with a perioperative mortality and complication rate of 1.5% and 8.5%, respectively. Seventeen of the 608 patients (<3%) were lost to follow-up. ResultsGastric bypass provides durable weight control. Weights fell from a preoperative mean of 304.4 lb (range, 198 to 615 lb) to 192.2 lb (range, 104 to 466) by 1 year and were maintained at 205.4 lb (range, 107 to 512 lb) at 5 years, 206.5 lb (130 to 388 lb) at 10 years, and 204.7 lb (158 to 270 lb) at 14 years.The operation provides long-term control of non-insulin-dependent diabetes mellitus (NIDDM). In those patients with adequate follow-up, 121 of 146 patients (82.9%) with NIDDM and 150 of 152 patients (98.7%) with glucose impairment maintained normal levels of plasma glucose, glycosylated hemoglobin, and insulin. These antidiabetic effects appear to be due primarily to a reduction in caloric intake, suggesting that insulin resistance is a secondary protective effect rather than the initial lesion. In addition to the control of weight and NIDDM, gastric bypass also corrected or alleviated a number of other comorbidities of obesity, including hypertension, sleep apnea, cardiopulmonary failure, arthritis, and infertility.

The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus.

Of 232 morbidly obese patients with non-insulin-dependent diabetes mellitus referred to East Carolina University between March 5, 1979, and January 1, 1994, 154 had a Roux-en-Y gastric bypass operation and 78 did not undergo surgery because of personal preference or their insurance companys refusal to pay for the procedure. The surgical and the nonoperative (control) groups were comparable in terms of age, weight, body mass index, sex, and percentage with hypertension. The two groups were compared retrospectively to determine differences in survival and the need for medical management of their diabetes. Mean length of follow-up was 9 years in the surgical group and 6.2 years in the control group. The mean glucose levels in the surgical group fell from 187 mg/dl preoperatively and remained less than 140 mg/dl for up to 10 years of follow-up. The percentage of control subjects being treated with oral hypoglycemics or insulin increased from 56.4% at initial contact to 87.5% at last contact, (P=0.0003), whereas the percentage of surgical patients requiring medical management fell from 31.8% preoperatively to 8.6% at last contact (P=0.0001). The mortality rate in the control group was 28% compared to 9% in the surgical group (including perioperative deaths). For every year of follow-up, patients in the control group had a 4.5% chance of dying vs. a 1.0% chance for those in the surgical group. The improvement in the mortality rate in the surgical group was primarily due to a decrease in the number of cardiovascular deaths.

Multicenter Trial of Sentinel Node Biopsy for Breast Cancer Using Both Technetium Sulfur Colloid and Isosulfan Blue Dye

ObjectiveTo determine the factors associated with false-negative results on sentinel node biopsy and sentinel node localization (identification rate) in patients with breast cancer enrolled in a multicenter trial using a combination technique of isosulfan blue with technetium sulfur colloid (Tc99). Summary Background DataSentinel node biopsy is a diagnostic test used to detect breast cancer metastases. To test the reliability of this method, a complete lymph node dissection must be performed to determine the false-negative rate. Single-institution series have reported excellent results, although one multicenter trial reported a false-negative rate as high as 29% using radioisotope alone. A multicenter trial was initiated to test combined use of Tc99 and isosulfan blue. MethodsInvestigators (both private-practice and academic surgeons) were recruited after attending a course on the technique of sentinel node biopsy. No investigator participated in a learning trial before entering patients. Tc99 and isosulfan blue were injected into the peritumoral region. ResultsFive hundred twenty-nine patients underwent 535 sentinel node biopsy procedures for an overall identification rate in finding a sentinel node of 87% and a false-negative rate of 13%. The identification rate increased and the false-negative rate decreased to 90% and 4.3%, respectively, after investigators had performed more than 30 cases. Univariate analysis of tumor showed the poorest success rate with older patients and inexperienced surgeons. Multivariate analysis identified both age and experience as independent predictors of failure. However, with older patients, inexperienced surgeons, and patients with five or more metastatic axillary nodes, the false-negative rate was consistently greater. ConclusionsThis multicenter trial, from both private practice and academic institutions, is an excellent indicator of the general utility of sentinel node biopsy. It establishes the factors that play an important role (patient age, surgical experience, tumor location) and those that are irrelevant (prior surgery, tumor size, Tc99 timing). This widens the applicability of the technique and identifies factors that require further investigation.

A new paradigm for type 2 diabetes mellitus: could it be a disease of the foregut?

SUMMARY BACKGROUND DATA We previously reported, in a study of 608 patients, that the gastric bypass operation (GB) controls type 2 diabetes mellitus in the morbidly obese patient more effectively than any medical therapy. Further, we showed for the first time that it was possible to reduce the mortality from diabetes; GB reduced the chance of dying from 4.5% per year to 1% per year. This control of diabetes has been ascribed to the weight loss induced by the operation. These studies, in weight-stable women, were designed to determine whether weight loss was really the important factor. METHODS Fasting plasma insulin, fasting plasma glucose, minimal model-derived insulin sensitivity and leptin levels were measured in carefully matched cohorts: six women who had undergone GB and had been stable at their lowered weight 24 to 30 months after surgery versus a control group of six women who did not undergo surgery and were similarly weight-stable. The two groups were matched in age, percentage of fat, body mass index, waist circumference, and aerobic capacity. RESULTS Even though the two groups of patients were closely matched in weight, age, percentage of fat, and even aerobic capacity, and with both groups maintaining stable weights, the surgical group demonstrated significantly lower levels of serum leptin, fasting plasma insulin, and fasting plasma glucose compared to the control group. Similarly, minimal model-derived insulin sensitivity was significantly higher in the surgical group. Finally, self-reported food intake was significantly lower in the surgical group. CONCLUSIONS Weight loss is not the reason why GB controls diabetes mellitus. Instead, bypassing the foregut and reducing food intake produce the profound long-term alterations in glucose metabolism and insulin action. These findings suggest that our current paradigms of type 2 diabetes mellitus deserve review. The critical lesion may lie in abnormal signals from the gut.

Surgical treatment of obesity and its effect on diabetes: 10-y follow-up.

Since 1980 we have performed the identical Greenville gastric bypass (GGB) procedure on 479 morbidly obese patients with an acceptable morbidity and a mortality rate of 1.2%. The weight loss in the series was well maintained over the follow-up period of 10 y. The GGB can control non-insulin-dependent diabetes mellitus (NIDDM) in most patients. The group of 479 patients included 101 (21%) with NIDDM and another 62 (13%) who were glucose impaired. Of these 163 individuals, 141 reverted to normal and only 22 (5%) remained with inadequate control of their carbohydrate metabolism. Those patients who were older or whose diabetes was of longer duration were less likely to revert to normal values. The gastric bypass operation is an effective approach for the treatment of morbid obesity. Along with its control of weight, the operation also controls the hyperglycemia, hyperinsulinemia, and insulin resistance of the majority of patients with either glucose impairment or frank NIDDM.

Persistence of sleep disturbances in preschool children

The purpose of our study was to determine if common sleep disturbances in young children, such as night waking and bedtime struggle, tend to persist; if they are related to environmental stress factors and are accompanied by other behavior problems; and if their persistence is related to other factors. Sixty children aged 15 to 48 months (mean age 26.4 months) were studied by interviewing their mothers initially and after 3 years. Children with and without sleep disturbances were compared, with the latter serving as the control group. Twenty-five (42%: night waking, 22%; bedtime struggle, 13%; both night waking and bedtime struggle, 7%) of 60 children had sleep disturbances at the initial interview, and of these 25 children, 21 (84%) had persistence of sleep disturbances after 3 years, persistent sleep disturbances had a significant relationship with increased frequency of stress factors in the environment (P less than 0.01). Other generalized behavior difficulties were present in 30% of sleep-disturbed and 19% of non-sleep-disturbed children (P = NS). Co-sleeping (sleeping with a parent or sibling) was noted more frequently in sleep-disturbed (34%) than in non-sleep-disturbed (16%) children. Twenty percent of the mothers at initial interview and 30% at 3-year follow-up perceived their childs sleep disturbances as stressful to them and to their family life. Early identification of the child with sleep disturbances and timely intervention would help both the child and the family.

Weight Loss in Severely Obese Subjects Prevents the Progression of Impaired Glucose Tolerance to Type II Diabetes: A longitudinal interventional study

OBJECTIVE To determine if weight loss may prevent conversion of impaired glucose tolerance (IGT) to diabetes, because weight loss reduces insulin resistance. The prevalence of IGT in the U. S. population is estimated at 11.2%, more than twice that of diabetes. Furthermore, because an oral glucose tolerance test is needed for its detection, most of these patients are undiagnosed. Screening for IGT would be meaningful if progression to diabetes could be delayed or prevented. RESEARCH DESIGN AND METHODS For an average of 5.8 years (range 2–10 years), 136 individuals with IGT and clinically severe obesity (>45 kg excess body weight) were followed. The experimental group included 109 patients with IGT who underwent bariatric surgery for weight loss. The control group was made up of 27 subjects with IGT who did not have bariatric surgery. The criteria of the World Health Organization was used to detect IGT and diabetes in this population. The main outcome measure of this nonrandomized control trial is the incidence density, or number of events (development of diabetes) divided by the time of exposure to risk. RESULTS Of the 27 subjects in the control group, 6 developed diabetes during an average of 4.8 ± 2.5 years of postdiagnosis follow-up, yielding a rate of conversion to diabetes of 4.72 cases per 100 person-years. The 109 individuals of the experimental group were followed for an average of 6.2 ± 2.5 years postbariatric surgery. Based on the 95% confidence interval of the comparison group, we would expect to find that between 22 and 36 subjects in the experimental group developed diabetes over the follow-up period. Only 1 of the 109 experimental-group patients developed diabetes, resulting in a conversion rate of the experimental group of only 0.15 cases per 100 person-years, which is significantly lower (P < 0.0001) than the control group. CONCLUSIONS Weight loss in patients with clinically severe obesity prevents the progression of IGT to diabetes by >30-fold.

The role of fine-needle aspiration biopsy in the rapid diagnosis and management of thyroid neoplasm.

This report describes our 5‐year experience with fine‐needle aspiration (FNA) biopsy of the thyroid in a 560‐bed teaching hospital. Three hundred nine FNA biopsies were performed primarily by one endocrinologist and interpreted by several pathologists. Analysis of the data reveals the sensitivity of the procedure is 93%, specificity is 95.1%, and the positive and negative predictive values are 88.9% and 96.5%, respectively. This data confirms the diagnostic accuracy of FNA biopsy. Complications were seen in 6 of 309 cases (1.9%) and were relatively mild. Nearly 75% of the cases in the series were cytologically diagnosed as nonneoplastic. Fine‐needle aspiration biopsy identified 19.4% of the cases needing surgery, of which 72% had neoplastic nodules, confirming the selection role of the procedure. The management of thyroid nodules is discussed and a selective review of the FNA literature is presented. The authors believe that our experience rebuts the argument that special referral centers are needed to interpret the cytologic material. Several well trained surgical pathologists can become proficient in interpreting the FNA biopsies without significant loss in accuracy, and thereby render a definite diagnosis in the vast majority of the cases. Accordingly, the authors recommend FNA of the thyroid as the initial diagnostic test in the evaluation of thyroid nodules.

Certification: It Does Matter:

The debate on certification requirements is flourishing in several states. Within the context of the debate is the assumption that a positive relationship exists between certification and teaching effectiveness. Although this assumption may be valid, the relationship is yet to be firmly established empirically. In this study, the authors examine the relation ship between mathematics teacher certi fication and teaching effectiveness. They report a positive relationship between the two variables and make suggestions for further study.

The control of diabetes mellitus (NIDDM) in the morbidly obese with the Greenville gastric bypass

Since February 1, 1980, the identical standardized Greenville Gastric Bypass has been performed in 397 morbidly obese patients with an operative mortality rate of 0.8%. The operation effectively controlled weight and maintained satisfactory weight loss even after 6 years (mean weights and ranges: Preoperative: 290 lbs (196-535); 18 months: 175 lbs (110-300); 72 months: 205 lbs (140-320). The gastric bypass favorably affected non-insulin-dependent diabetes (NIDDM), hypertension, physical and role functioning, and several measures of mental health. Rigorous follow-up (97.5% over 6 years) revealed that health problems were common in postoperative patients; there were nine late deaths. Abnormal glucose metabolism was present in 141 (36%) of 397 patients before surgery: NIDDM was present in 88 patients (22%) and 53 patients (14%) were glucose impaired. Of these, all but two became euglycemic within 4 months after surgery without any diabetic medication or special diets. The most recent 42 morbidly obese patients with NIDDM were studied intensively. In that cohort, fasting blood glucose, fasting insulin, and glycosylated hemoglobin returned to normal after surgery; insulin release, insulin resistance, and utilization of glucose improved sharply. The normalization of glucose metabolism after gastric bypass may not be related solely to weight loss and restriction of caloric intake, but may also be due to the bypass of the antrum and duodenum.